This is the third article in a series from The Doctors’ Company (TDC) on risk management. For any questions or comments on liability issues, call TDC at (800) 421-2368, ext. 243.
All malpractice claims have anger as a root cause. Whether anger is emitted from the patient, the doctor, or both-it is always present. Virtually every patient contemplating medical treatment experiences some degree of anxiety. In seeking a physician, patients also seek reassurance against their uncertainties. An unfavorable treatment outcome evokes feelings of despair and helplessness that can quickly turn into hostility. Regardless of the true cause, the anger will be focused on the most convenient and visible target-the doctor.
Let Them Vent
When faced with someone who is upset or angry, it is best to remain silent and to let that person talk about the problem. Respond with noncommittal comments such as “yes” or “uh-huh” until the patient has calmed down. This technique of attentive silence often defuses angry people. Once the patient has finished expressing dissatisfaction, calmly ask him or her to reiterate part of the message, even though you may have understood it. Requesting additional information or an explanation reinforces the importance you attach to the patient’s message.
One of the worst errors you can make in dealing with angry or dissatisfied patients is to try to avoid them. Although such a reaction is understandable, avoidance is the surest way to hasten a patient’s visit to the attorney. As difficult as it may be, the more you talk and listen to an angry patient, the more likely you are to avoid converting an incident into a claim. Assuming responsibility for at least 55 percent of the effort necessary for effective communication will substantially improve your chances for successful doctor-patient relationships.
Your Own Anxiety
An unfavorable outcome also produces anxiety in a physician. More often than not, patient complaints are interpreted as personal affronts that strike at your sense of professionalism, pride and competence.
When you perceive a complaint as unwarranted, communication with the patient may quickly degenerate into mutual hostility. A vicious cycle is then established: Your anxiety, guilt, hostility and arrogance are countered by the patient’s hostility, which causes your hostility to mount. In such a climate, the possibility of a lawsuit quickly becomes a probability. Regardless of the nature of a complaint, all malpractice actions are preceded by these negative emotions.
It is very difficult, if not impossible, to be objective when it seems that a lawsuit soon may be hanging over your head. Therefore, controlling the course of events prior to the onset of mutual hostility is key to avoiding malpractice actions. The pretreatment or postoperative consultations during which informed consent is obtained provides an excellent opportunity to establish a positive doctor-patient relationship that can weather an unfavorable outcome.
Sharing Uncertainty
Much has been written on the therapeutic effects of full informed consent. Simply stated, the very act of disclosure results in less anxiety, increased trust in the integrity of the physician, a smoother clinical course and better patient understanding should anything go awry. Experience has shown, however, that unless both doctor and patient fully understand the significance of the transaction, both can be lulled into a false sense of security.
Many physicians are reluctant to use consent forms for fear of calling attention to a long list of potential complications that could unnecessarily heighten a patient’s unspoken anxieties. Conversely, the ritualistic but meaningless signing of a document (reading a list and obtaining a signature) can give you the false assumption that all bases have been covered and that an unpleasant but necessary formality has been completed.
Ideally, the informed consent sessionshould be viewed as an opportunity to dispel uncertainty, allay anxiety and help fill the gap between patient ignorance and supposed physician omnipotence. By sharing uncertainty, you can transform a potentially adversarial relationship into a therapeutic alliance.
Presenting a Human Image
The essence of rapport lies in patient confidence in his or her physician. In many therapeutic situations, the patient’s principal defense mechanism against uncertainty is to endow you with a certain omnipotence. Thus, according to psychiatric authors, an irrational yet real relationship evolves in which the patient is totally dependent on you, the doctor. In this state of physical and emotional dependence, patients are unwilling or unable to accept any disavowals that intrude on the illusion.
Furthermore, if an unfavorable outcome shatters the magic, disillusionment might increase the dependent state. Patients may also refuse to accept prior knowledge of the possibility of such an outcome or to even assume partial responsibility for self-care. At that point in the patient’s regressive state, the treating physician becomes a target.
Logically, you should try to dispel any fantasies or unrealistic expectations before treatment begins. However, confronting such expectations directly may irreparably damage the patient’s sense of confidence in you. This approach may even impair a successful therapeutic outcome.
How can you prepare patients without sabotaging their confidence? Consider, for example, the following statements:
“Here is a list of complications that could occur during your treatment or operation. Please read the list carefully and sign it. If you don’t understand something, ask me.”
“I wish I could guarantee that there will be no problems during your treatment or operation, but that wouldn’t be realistic. Sometimes there are problems that cannot be foreseen, and you need to know about them. Please read about them and let’s talk about it.”
By using the second statement, you can reduce the omnipotent image the patient has of you to that of a more realistic and imperfect human being. The patient will see that you are facing, and thus sharing, the same uncertainty. The implication is clear: “We-you and I-are going to cooperate in doing something to your body that will make you better, but there are no guarantees on how your body will respond.”
Sense of Participation
Be cautious, however. In an effort to ease anxiety, your reassurance to the patient may overreach and create unwarranted expectations and an implied guarantee. Note the difference in the following statements:
- Don’t worry about a thing. I’ve taken care of hundreds of cases like yours. You’ll do just fine.
- Barring any unforeseen problems, I see no reason why you shouldn’t do very well. I’ll certainly do everything I can to help you.
Again, by using the second statement, you will gently deflate the patient’s fantasies of you to realistic proportions, while remaining reassuring and helping the patient accept reality.
The therapeutic objective of informed consent should be to replace some of the patient’s anxiety with a sense of participation and some control. This strengthens the therapeutic alliance between the patient and the physician. Instead of regarding each other as potential adversaries, both come closer in the shared acceptance of the uncertainties involved in clinical practice. Discussing consent forms will allow you and your patients to know each other better. Your patients will also realize they are in the care of a concerned physician.
How Patients Cope
It is entirely appropriate for patients to feel a sense of bewilderment and anxiety when medical treatment does not go smoothly. The borderline between anxiety and anger is very tenuous, with fear of the unknown as the critical factor.
How do people cope with uncertainty? Blamingsomeone else places the responsibility elsewhere and gives a sense of control that, however inappropriate, is easier to cope with psychologically. A patient who is frightened by a postoperative complication and is uncertain about the future can gain a distorted sense of security by blaming the physician. The logic of this distortion is: “If it is the doctor’s fault, it is the doctor’s responsibility to correct.” Thus, the scenario is set: A frightened patient, unaware of the underlying reason for his or her anger, lashes out at the physician with the subconscious perception that such action will get matters under control and force the doctor to produce a favorable result.
Encourage Trust
A patient’s distorted perceptions may clash head-on with your understandable anxieties and wounded pride. The patient blames you and, in turn, you feel defensive. At this critically delicate juncture, your reaction can either set into motion or prevent a chain reaction of increasing hostilities.
You are probably dealing with a frightened patient who is using anger to gain control of the situation. Make a supreme effort to put aside natural feelings of disappointment, anxiety, defensiveness and hostility. The entire mood and subsequent developments in your doctor-patient relationship can be affected by the amount of understanding, support and encouragement you can lend to the situation. A patient’s perception that you understand his or her uncertainty and that you will help conquer it can be the deciding factor in whether or not the patient will seek legal counsel.
By creating an atmosphere of trust and partnership, you can relieve your patients’ anxieties and diffuse their anger. Without anger or hostility, you and your patients can work together as partners to decide their medical care plans.
Mark Gorney, MD, is a plastic surgeon and medical director of The Doctors’ Company. Joan Bristow, RN, MA, is vice president of TDC Risk Management. TDC offers malpractice insurance at a reduced rate as a benefit of AANS membership.